Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

Abstract

Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., "Preservation", "Reconstruction", and "Reinforcement" of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m², 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence.

Keywords: lower urinary tract; prostate cancer; radical prostatectomy; robot; urinary incontinence.

Fig. 1.

Preservation of membranous urethral length during robot-assisted radical prostatectomy (A) Representative photograph before dividing between urethra and prostate Before dividing urethra and prostate, it is important to clearly show the association between urethra and prostate to preserve the postoperative membranous urethral length. (B) Representative photograph during the dividing between urethra and prostate Urethra was cut as nearly as possible at the prostatic apex. UR; urethra, PR; prostate

Fig. 2.

Artifice of preserving the membranous urethral length We take minimal bites of the needle at the anterior aspect of the Ω-shaped membranous urethra during vesicourethral anastomosis at robot-assisted radical prostatectomy to leave it long postoperatively. UR;urethra, BL;bladder

Fig. 3.

Representative photograph of posterior reconstruction of Denonvilliers’ fascia by using modified Rocco technique Disconnected rhabdosphincter in the posterior aspect of the urethra and Denonvillers’ fascia in the bladder neck were attached to enhance the suspension of the posterior aspect of the urethra and prevention of shortening of the membranous urethra. UR;urethra, DF;Denonvilliers’ fascia

Fig. 4.

Bladder neck suspension technique Bladder neck is lifted by absorbable suture situated under the vesicourethral anastomotic site. This absorbable suture was fixed at the posterior part of the pubic bone in the periosteum.

Fig. 5.

Bladder neck plication technique Bladder neck was plicated by running stich at the 2 cm proximal site of vesicourethral anastomosis.

Fig. 6.

Vesicourethral anastomosis by using running suture Vesicourethral anastomosis for laparoscopic radical prostatectomy or robot-assisted radical prostatectomy is usually performed using running sutures in many institutions. This anastomosis technique represents the Van Velthoven stitch. UR;urethra, BL;bladder

Fig. 7.

Postoperative urethral and periurethral tissue on sagittal T2-weighted images from postoperative magnetic resonance imaging (MRI). (A) Mild damage to the urethra and surrounding tissue. (B) Severe damage to the urethra and surrounding tissue.

Fig. 8.

Putative mechanism of de novo overactive bladder after radical prostatectomy induced by urinary pooling inside the urethra Urinary leakage into the urethra owing to deficient urethral sphincter function stimulates afferent nerve activity, resulting in inducing urgency after radical prostatectomy.